HIPAA Statement

Notice of Privacy Practices

The Notice of Privacy Practices is required by the Privacy Regulations stemming from the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Notice of Privacy Practices explains how your medical information may be used or disclosed and how you can get access to your medical information. This practice is determined to protect the privacy of your medical information. As we provide service to you, we create and store health information (a medical record) that identifies you. It is often necessary to share or disclose this health information in order to provide treatment for you, obtain payment, and to conduct healthcare operations in our office.

This Notice of Privacy Practices requires us to:

1. Keep your medical records private and to provide you with this notice.
2. Change our privacy practices and the terms of this notice any time, ensuring that our notice is effective, even for information recently obtained.
3. Before we make an important change in our privacy practices, change this notice and make the new notice available upon request.

Circumstances in which we may use or disclose your medical information:

4. Share medical data with another provider who is responsible for your care (physicians, audiologists, nurses, any other healthcare professionals, technicians, students in health care, or any other people who take care of you), make referrals, and place lab or prescription orders.
5. Share your health insurance plan information about a treatment you received at our practice when filing a claim for reimbursement or determination of benefits.
6. Disclose your medical information for our healthcare operations.
7. Share information about your condition(s), location, and/or death to family member(s), or your personal representative(s). Prior permission by you will be obtained unless in case of emergency.
8. Disclose medical information to a medical examiner to identify a deceased person or to determine the cause of death, or for tissue donations.
9. Medical information may be disclosed if you are military personnel, either active or a veteran, and if required by the appropriate authorities.
10. Share medical data to the public health and/or law enforcement official whose job is to prevent or control disease, injury, or disability.
11. Share medical data to a representative from the Food and Drug Administration for the purposes of reporting adverse effects stemming from defective products.
12. Medical information may be disclosed when necessary to comply with Workers Compensation.
13. Medical information may be disclosed in response to a court and/or administrative order in a lawsuit or similar proceeding.

Your individual rights as a patient of Elevate Audiology:

• Photocopies of your medical records on file and/or a copy of this Notice of Privacy Practices. If you need a photocopy, please notify the receptionist.
• Receive a list of all the times your medical information has been shared by our office or our business associates, other than treatment, payment, healthcare operations, and other specified exceptions.
• Request that we communicate with you about your medical information by different means or to different locations. This request must be made in writing to Elevate Audiology.
• Request a change to your health information if you think it is incomplete or inaccurate. However, if the audiologist or office personnel believe the patient’s health information is complete and accurate, he or she can refuse to make the requested changes. This request must be made in writing to Elevate Audiology.
• Request a paper copy if you received this Notice of Privacy Practices electronically. This request must be made in writing to Elevate Audiology.

You have the right to restrict the uses or disclosures made for purposes of treatment, payment, and healthcare operations, but we are obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. If you have any questions regarding this, please contact Elevate Audiology.

If you think that we may have violated your privacy rights, contact Elevate Audiology. If your concern is not resolved, you may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. If you choose to file a complaint, we will not retaliate in any way.

The Privacy Rule portion of the HIPAA regulations requires our practice to submit a copy of the Notice of Privacy Practices to each patient, both existing and new. If the patient refuses to sign the notice, Elevate Audiology is not obligated to treat the patient.

I have read and have been provided an opportunity to review the Notice of Privacy Practices. I agree that my Elevate Audiology professional can and will use and disclose my health information to treat me, to obtain payment for our services, and to perform healthcare operations.